In this study, as we have stated before, we used the TSD technique in order to find out the effectiveness of this psycho- logical technique in the presence of the other two variables, namely the prelimi- nary preparation at home prior to the children’s visit to the dentist’s and the presence of the mother at the operatory room. All the children in all three groups whose behavior was controlled, were subjected to simple treatment mea- sures, namely clinical examination by using mirror and explorer, oral prophylaxis and applying the fluoride.

Before starting the treatment steps, and as a part of the psychological treatment plan which aims at gaining the child’s confidence and breaking the barrier of fear, we were very careful to call each child by his name and invite him kindly to sit on the dental chair. At the same time, the tools to be used were pre- pared in a simple manner that children like. Each tool was given a pleasant name of a famous cartoon character to bring it close to the mind and imagina- tion of the child. The child was invited to touch and feel those tools by hand. Also, the child was given the chance to hear the unpleasant sounds of surgical suction and the cleaning drill. The child was allowed to experience the feeling of the water and air used in washing and drying, in order to introduce him/her to the general nature of the thing they would be experiencing. Furthermore, the dentist explained to the child the necessary treatment steps, elaborately,but simply and in a language appropriate to the mental ability of the child.

Group C

In this group, regardless of age, almost all the children were more afraid, tense and hesitating. A longer time was need- ed to control the children in this group in order to convince them to accept the treatment and to make them feel secure, compared to the other two groups. Females were, as usual, more positive than males. The older children were more cooperative than the younger ones, as was the case in the previous two groups. There were six cases of total absence of cooperation. Response in this group was average compared to the other two groups. More time and effort was needed to control the children and to accomplish the treatment.

Discussion

The results we arrived at were most important in identifying the factors that affect the behavior of children at the clinic. The study has proved beyond doubt that the preliminary preparation of the child by the mother, in a studied mental and psychological way, is impor- tant and effective in reducing the fear of the child.1,2,3 This was very clear in the first and second groups, where the child was prepared psychologically before the visit. The children in the third group, who were not prepared at home by their parents, needed more time and effort to control and calm. We believe, this is because man is enemy of what he does not know. It is important to inform the child about the nature of the dentist’s work, and the damage that will result from not going to the dentist. For this reason, it is advised that the child’s first visit to the dentist take place before any teeth problems start.

With regard to age as a factor affect- ing the child’s behavior at the clinic, we found that there is a direct relationship between age and positive conduct of the child at the clinic. This means that a 6-year-old child is more cooperative

and responsive to the doctor’s instruc- tions than a 3-year-old child. This is so because of the increased cognitive, mental, conceptual and psychological growth.4,5 An elder child is more able to communicate and respond to the den- tist’s directions. However, there are exceptions to every role, as can be seen in the higher degree of cooperation by younger children in the first two groups in which there was preliminary prepara- tion prior to their visit to the dental clin- ic. This means that age is not the only factor affecting the child’s cooperation in the dental clinic, but there are sever- alothers.Otherfactorsincludesuchas the educational and cultural level of the parents, the social status of the child within the family and among his broth- ers.6 Is he an only child or not?. Generally, we found that the older the child was, the easier it was to deal with him.

With regard to the factor of sex, we found that females were more respon- sive than males regardless of the pre- liminary preparation or presence or absence of the mother at the clinic. This might be because of the more quiet nature of females. This result is different from that reached by Frankl and others.3 The effect of the presence of the moth- er on the conduct of the child at the clin- ic was of two different and opposite effects.3,6,7,8 Sometimes we found that it was necessary for the child to be treat- ed in the presence of his mother, in view of the age of the child, his medical and mental status and whether the mother was anxious or not.6,9,10,11 We allowed the mother to be with us as a witness or observer only, with no right to affect the child’s behavior or interfere with the dentist’s work. Meanwhile, when the mother was too anxious, we would ask her to step out of the clinic until we fin- ished our work to avoid any negative effect on her child. Older children were more independent and self-confident. Their behavior was more settled than that of younger children. The presence or absence of their mother did not make any difference. Also, we found that keeping the mother away from the child during the treatment was much better than being with him.6,7 This is because the doctor had to use certain tech- niques, such as voice control and / or HOME technique (Hand Over Mouth Exercise) to control the unpleasant behavior of an uncooperative child.12 The mother might think that these are punitive measures used with her chil- dren, and so she would tend to interfere and sometimes request to stop the treatment.

In addition, in this study, we made two interesting observations: the first is that when the mother was more afraid and anxious, her child would also be more afraid,especiallyamongtheyounger children.6,7,8,13,14 This is because the fear of the dentist is an acquired rather than native one. Many studies demonstrated many years ago that parents can and do convey their negative attitude (fear) to their children.5

The second is that the children who studied at foreign schools were more responsive and better equipped to adapt to the situation, compared with those who studied at government school. This underlines the necessity of increasing awareness in children.

In this research, we preferred to use the psychological approach rather than other approaches such as the pharma- cological approach and/or restricting the movement of the child. We did encounter some children who were too difficult to be controlled by psychologi- cal means, particularly within the third group who were not prepared for the visit at home. The existence of uncoop- erative children is a normal sign, because no doctor can possibly control the behavior of 100% of the children within a period of 30 – 45 minutes. This is because the image of fear, whether that fear was acquired or expressed by the child as a result of unpleasant expe- rience, can stay with a child for a long time, and for this reason a number of uncooperative children were treated under general anesthesia.

We now return again to the reason why we chose the psychological way rather than other available ways; this is because we strongly believe that psy- chology plays an important role in the child’s management and treatment in the dental clinic. ”Man is the enemy of what he ignores”, and for this reason the doctor’s duty is psychological in the first place and one of the treatment in sec- ond place. Unless the doctor is able to gain the confidence and love of the child, he cannot treat him properly. The dentist should be kind and pleasant when he meets the child. He should call him by his name from the start in order to break the barrier of fear in the mind of the child. He should also understand the child’s language and be able to understand and analyze his psychology before starting the treatment, and he should be kind but firm.